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Ependymoma grade II, case 1

 

Clinical history
50-year-old male.
Slowly progressive sensory abnormalities of both hands for 6 months. Recently, the patient developed myoclonic episodes of the right arm.

Neurological examination
Hypoesthesia of both upper limbs was noted , with loss of temperature sensation in both hands and proprioceptive sensation of the fingers. The tendon reflexes were normal. Somesthesic evoked potentials were altered.

Preoperative MRI
Image 1: Sagittal T1WI. Progressive cervical cord enlargement including C2 to C7. A discretely hyperintense solid component is seen at C4-C5 level.
Image 2: Sagittal T2WI. On those sagittal T2WI, the solid component is better identified, isointense to normal cord and clearly delineated due to the presence of associated hyperintense cystic components at the lower end. Edema is also seen superior to the lesion.
Image 3: Sagittal Gd T1WI. After Gadolinium injection, the solid nodule enhances intensely although irregularly. Tumor borders are well delineated. No contrast enhancement is seen at the periphery of the associated cyst.
Image 4: Axial Gd T1WI. It is important to observe that contrast enhancement is located at the center of the medulla. This finding points strongly to a centrally located tumor: ependymoma?

Surgery
Complete resection of an intramedullary tumor was successfully achieved.

Histology
Ependymoma grade II.

Clinical follow-up
Immediately after surgery, sensory impairment of all limbs worsened, but subsequently improved. Dysesthesia of the fingers of both hands persisted.

Postoperative control MRI
Image 5: Sagittal T1WI and image 6: Gd T1WI. These follow-up images show only mild changes within the spinal cord and no abnormal contrast enhancement at the site of surgical resection.
Image 7: Sagittal T2WI. Additionally, these sagittal T2W images show reduction of the size of the cystic component. Disappearance of the intramedullary edema is seen. Focal thinning at the site of resection with few low signal areas due to hemosiderin deposits can be observed.
Image 8: Axial T1WI and image 9: axial Gd T1WI. These axial images confirm the reduction of the cystic component. Still, after Gadolinium injection, a small enhancing nodular lesion is suspected and a serial follow-up examination advised.

Follow-up
A new postoperative follow-up MRI performed more than one year after surgery is shown.

Image 10: Sagittal T1WI, image 11: sagittal Gd T1WI, image 12: sagittal T2WI and image 13: axial GdT1WI. No interval change is noted and a very small contrast enhancing nodule is seen again.

Differential diagnosis
Small persistent tumor versus postoperative changes.
The neurological status of the patient is satisfactory and stable.

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Fig. 1

Ependymoma grade II, case 1, Fig. 1
Ependymoma grade II, case 1, Fig. 2
Ependymoma grade II, case 1, Fig. 3
Ependymoma grade II, case 1, Fig. 4
Ependymoma grade II, case 1, Fig. 5
Ependymoma grade II, case 1, Fig. 6
Ependymoma grade II, case 1, Fig. 7
Ependymoma grade II, case 1, Fig. 8
Ependymoma grade II, case 1, Fig. 9
Ependymoma grade II, case 1, Fig. 10
Ependymoma grade II, case 1, Fig. 11
Ependymoma grade II, case 1, Fig. 12
Ependymoma grade II, case 1, Fig. 13